Interventions to improve foster children’s mental and physical health A systematic review and assessment of the economic, social and ethical aspects sbu assessments | assessment of methods in health care and social services september 2017 | www.sbu.se/265e
Executive summary photo: magnus glans
Many maltreated or troubled children and youth are placed in foster family care for shorter or longer periods. Those children have substantially increased risks of mental and health problems compared to other children, at time of care entry, while in care and in adulthood. It is therefore important to know if interventions for children residing in foster care are effective. Conclusions ` Interventions to children in foster care and their foster parents can improve the children’s psychological and physical health, social situation, quality of life, and also the stability of placements. Due to the differences between the interventions and variation in the scientific design of the studies, it is not possible to determine which interventions or parts of these activities are better than others. ` There is evidence that three specific interventions are effective: • Attachment and Biobehavioral Catch-up targeting foster parents can improve children’s attachment behaviors • Incredible Years can improve parenting abilities of foster parents, as well as decrease children’s externalizing behaviors • Take Charge for young people can improve children’s self-determination skills, high school completion and increase their likelihood of future employment. For the other 15 interventions that were identified in the systematic review, there was not sufficient studies to assess their effects, when applying the GRADE-model of assessing evidence from evaluations. The absence of
robust evidence for these interventions does not necessarily imply that they are ineffective, rather that the empirical evidence is not up to GRADE-standards. ` None of the interventions currently used in Sweden have been evaluated in controlled trials. In Swedish foster care service, emphasis is on investigating foster parent’s suitability and preservice training. Providing structured interventions for children and foster parents in a systematic way when the child is in foster care is far less common. People who have grown up in foster care, their birth and foster parents – all express desires for interventions that support both children and foster parents during placement. ` Far more research is needed to assess the impact of foster care interventions. All 18 interventions that the systematic review identified can presumably be successfully implemented in the Swedish context, but their effects should be evaluated in Sweden. The interventions already in use in Sweden need to be evaluated. Studies that highlight cost-effectiveness of interventions for foster children are generally few and far in-between, and totally absent in a Swedish context.
sbu – swedish agency for health technology assessment and assessment of social services
1
Background and Aims Three to four percent of children in Sweden are at some time during their formative years placed in foster or group care. These children are at increased risk for suicide, poor mental and physical health, addiction, criminality and need for long-term economic support in late adolescence and adulthood. The aim of this report is to review and synthesize the scientific evidence for supportive interventions, targeting children in foster care and their foster parents. Method The systematic review was conducted in accordance with SBU’s methodology (www.sbu.se/en/method). Included studies are evaluations of interventions in controlled trials with high or medium quality, published between 1990 and 2017 and include at least 40 participants. Follow-up time was at minimum three months or more for children two years or older, and one month or more for children younger than two years. Studies were excluded if the comparison group consisted of group care or if more than 30 percent of children were in kinship care. The systematic review also includes economic aspects, an inventory of the interventions used in Sweden, and expressed experiences of foster care by representatives of non-profit organisations for individuals with a history of foster care. Ethical aspects are discussed based on the results. Results Systematic review A total of 5,298 abstracts were reviewed, and of these, 23 studies of 18 interventions matched the inclusion and exclusion criteria. The 23 studies (20 RCT, 3 CT) prove that it is possible for interventions to have impact on the mental and physical health, social situation, quality of life, and stability of placements of foster children. Due to differences between the interventions and the dissimilarities in scientific design, the results do not provide sufficient information on what the common elements of these effective interventions might be. For three interventions, there is limited scientific support for positive effects: Attachment and Biobehavioral Catch-up can improve children’s attachment; Incredible Years can increase foster parents’ parenting skills, as well as decrease children’s externalizing behaviors; Take Charge can improve youth’s skills of self-determination, their high school completion and their future employment prospects. The
2
effects of the remaining 15 interventions cannot be assessed with sufficient levels of robustness since they have only been evaluated in single studies. The interventions included in the systematic review are estimated to be implementable in the Swedish context and could possibly demonstrate effects similar to the original trials. None of the studies included outcome measures on the child’s dental health, and teenage pregnancies. There are also no studies that map possible harmful or unwanted effects of the interventions. For information on the trials, see Overview of results per intervention on www.sbu.se/265e. Interventions used in Swedish foster care In 2016, a survey was sent to a random sample of municipalities (response from 80/106) and to all forprofit organisations commissioned by municipalities to provide support in foster care (responses from 34/38). A total of 30 brand (named) interventions were identified. None of these were identified in the systematic review. Swedish foster care services seem to focus mainly on recruiting suitable foster parents (91% of municipalities and 97% of companies) and on pre-placement training of foster parents (78 and 62%). Significantly fewer municipalities and companies offered children (19 and 26%) or foster parents (19 and 23%) some kind of systematic and structured support during placement. Due to the large number of different interventions targeting children or foster parents, our conclusion is that there seems to be no professional consensus in Sweden on what interventions are presumed to be effective. Cost effectiveness Out of 2,120 reviewed abstracts, 2 articles were relevant, but none met the SBU’s quality requirements in economic evaluations or where the results could be transferred to a Swedish context. Perspective from non-profit organisations Four organisations representing individuals who had been in foster care, and both birth parents and foster parents, answered questions about their views of foster care. In unison, they called for targeted support in addition to foster care placement itself. In addition, foster parents wanted more relevant information about the child’s needs of support and help before the placement, in order to prepare themselves. Birth parents stressed the need of effective support being provided for their children during the placement.
interventions to improve foster children’s mental and physical health
Ethical and Social Considerations When society takes the responsibility for child custody away from biological parents, there is an obligation to satisfy the child’s best interests (the principle of in loco parentis). These obligations are sometimes not met, as shown most dramatically in an official report produced by the Swedish government on child maltreatment in out-of-home care (SOU 2011:61), as well as the information from the four organisations that were heard in connection with this literature review. One obvious obstacle for improving foster care services is the lack of evidence as to what constitutes effective interventions. Another is that professionals seldom document and follow-up presently administered interventions.
are faced with other challenges. Even if there were to be increased access to evidence on effective interventions, routines are needed to help local authorities implement, retain and in some cases probably abandon current interventions in foster care practice. To make this successful, local monitoring is needed where both positive and negative effects are systematically documented and analyzed. Another challenge is that those who work in foster care services often lack experience with the systematic approach normally required for these types of interventions. This problem may be accentuated in smaller municipalities with few children in foster care, leaving professionals with few opportunities to stage and practice new interventions.
Discussion Evidence-based foster care interventions are needed to support foster children (and foster parents), including interventions targeting the child under placement. However, in addition to the lack of valid research to guide the choice of interventions, many municipalities (290 in Sweden, responsible for child welfare)
Future research in Sweden should focus on
Experts Martin Bergström, Ph.D. Associate Professor, School of Social Work, Faculty of Social Sciences, Lund University Marianne Cederblad, Professor Emerita, Lund University
• Investigating the benefits of the efforts currently being used.
SBU Knut Sundell, Project Manager
Article 265e
Project group
• Staging in-country trials of interventions that have shown good effects in other national contexts
Kickan Håkanson, Project Administrator Pia Johansson, Health Economist Ann Kristine Jonsson, Information Specialist Pernilla Östlund, Assistant Project Manager
Christian Munthe, Professor of Practical Philosophy, Department of Philosophy, Linguistics & Theory of Science, Centre for antibiotic resistance research (CARe), Centre for ethics, law and mental health (CELAM), University of Gothenburg Bo Vinnerljung, Professor Emeritus of Social Work, University of Stockholm; Senior Researcher, Clinical Epidemiology/Department of Medicine, Karolinska Institutet, Stockholm Ingegerd Wirtberg, Ph.D. Senior Lecturer, Cert Psychotherapist, Department of Psychology, Lund University
SBU Assessment no 265, 2017 www.sbu.se/en •
[email protected]
sbu assessments • report 265e
Scientific reviewers Clara Hellner, MD, Ph.D. Professor, Centre for Psychiatric Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm Titti Mattsson, Professor of Public Law, Faculty of Law, University of Lund Terje Ogden, Ph.D. Developmental Psychology, Clinical Psychology, Department of Psychology, University of Oslo and The Norwegian Center for Child Behavioral Development, Oslo, Norway
Graphic Design: Elin Rye-Danjelsen, SBU
3
